Professional Documents
Culture Documents
04/14/2016
Remediation A
Ergonomics are the factors or qualities in an objects design and/or use that
contribute to comfort, safety, efficiency, and ease of use.
Using good body mechanics when positioning and moving clients promotes
safety for the client as well as for health care providers.
Before attempting to position or move a client, the nurse should perform a
mobility assessment.
Begin this assessment with the easiest movements (range of motion) and
progress as long as the client tolerates it (balance, gait, and exercise)
Nurses can only delegate tasks appropriate for the skill and education level of
the health care provider who is receiving the assignment.
RNs cannot delegate the nursing process, client education, or tasks that
require clinical judgment to LPNs or AP.
Task factors Prior to delegating client care, the nurse should consider:
Predictability of outcome, Potential for harm, Complexity of care, Need for
problem solving and innovation, and Level of interaction with the client
Initiate the necessary consults or notify the provider of the clients needs so
the consult can be initiated.
Provide the consultant with all pertinent information about the problem
(information from the client/family, the clients medical records).
Incorporate the consultants recommendations into the clients plan of care.
Confidentiality/Information Security
Professional Responsibilities: HIPAA Violation
Only health care team members directly responsible for the clients care
should be allowed access to the clients records. Nurses may not share
information with other clients or staff not involved in the care of the client
Clients have a right to read and obtain a copy of their medical record, and
agency policy should be followed when the client requests to read or have a
copy of the record.
Client medical records must be kept in a secure area to prevent
inappropriate access to the information. Using public display boards to list
client names and diagnoses is restricted.
Electronic records should be password-protected, and care must be taken to
prevent public viewing of the information.
Informed Consent
Professional Responsibilities: Providing Translation for Informed Consent
The person who signs the form must be capable of understanding the
information provided by the health care professional who will be providing the
service, and the person must be able to fully communicate in return with the
health care professional.
When the person giving the informed consent is unable to communicate due
to a language barrier or hearing impairment, a trained medical interpreter
must be provided.
Many health care agencies contract with professional interpreters who have
additional skills in medical terminology to assist with providing information.
Accident/Error/Injury Prevention:
Client Safety: Impaired Vision
For clients who are sedated, unconscious, or otherwise compromised, the bed
rails are kept up, and the bed is kept in the low position
Older adult clients may be at an increased risk for falls due to decreased
strength, impaired mobility and balance, and endurance limitations combined
with decreased sensory perception.
Other clients at increased risk include those with decreased visual acuity,
generalized weakness,
urinary frequency, gait and balance problems (cerebral palsy, injury, multiple
sclerosis) and cognitive dysfunction. Side effects of medications (orthostatic
hypotension, drowsiness) also can increase the clients risk for falls.
Interventions:
Reassuring.
No interventions required
Indicate reactive nonstress test
Health Screening
Abuse/Neglect
Family and Community Violence: Priority Interventions
Nursing interventions for child or vulnerable adult abuse must include the
following:
o Mandatory reporting of suspected or actual cases of child or vulnerable
adult abuse.
o Complete and accurate documentation of subjective and objective data
obtained during assessment.
o A forensic nurse has advanced training in the collection of evidence for
suspected or actual cases of sexual assault or other forms of physical
abuse
Assistive Devices
Apply heat or cold to the affected areas as indicated based on client response
Assist with and encourage physical activity to maintain joint mobility (within
the capabilities of the client).
Monitor the client for indications of fatigue.
Teach the client measures to maximize functional activity
Medication Administration
Medications for Depressive Disorders: Amitriptyline
Have client sit upright or lie supine with the head tilted slightly and looking
up at ceiling.
Rest dominant hand on clients forehead, hold dropper above conjunctival sac
approximately 1 to 2 cm, drop medication into center of sac, and have client
close eye gently.
Apply gentle pressure with finger and a clean tissue on nasolacrimal duct for
30 to 60 seconds to prevent systemic absorption of medication
Parenteral/Intravenous Therapies
Diagnostic Tests
Assessment of Fetal Well-Being: Clients in Need of Fetal Monitoring
Therapeutic Procedures
Respiratory Diagnostic Procedures: Nursing Interventions for a Thoracentesis
Apply a dressing over the puncture site, and assess dressing for bleeding or
drainage.
Monitor the clients vital signs and respiratory status (respiratory rate and
rhythm, breath sounds, oxygenation status) hourly for the first several hours
after the thoracentesis.
Auscultate lungs for reduced breath sounds on side of thoracentesis.
encourage the client to deep breathe to assist with lung expansion
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Medical Emergencies
Gastrointestinal, Structural, and Inflammatory Disorders: Reportable Findings